By David Healy Harvard University Press, 1997 Review by Jonathan M. Metzl, M.D. on Nov 10th 1998
It seemed the cleanest of rebellions. In the 1950s psychoanalysis was the power force in American academic psychiatry. The influence of psychoanalysis was felt in all corners of the profession. Psychoanalysts, for example, dominated the American Psychiatric Association subcommittee that produced the initial Diagnostic and Statistical Manual, 1st edition. Psychoanalysts were the chairmen and professors of the nation's leading departments of psychiatry. And psychoanalysts controlled the editorial boards of many leading professional journals.
Beneath the "ivory towers" of nosology and treatment, however, a blue-collar band of psychiatrists was hard at work proving that treatment was a chemical rather than merely a verbal intervention. These men -- and only men, it would seem -- invented, tested and perfected compounds which would change the ways mental illnesses were diagnosed and treated. When the time was right, these men brought their compounds into the world of clinical psychiatry; and in so doing, permanently altered the power balance in the field. Where the id of psychoanalysis was, there shall the ego of biology be.
The reality of a paradigm shift, however, is never as tidy as a simple binary suggests. Instead, it involves a myriad of forces working for, and often against, what is ultimately defined as progress. The specifics of how this process has played out in psychiatry in the past fifty years is the subject of Psychiatrist-Historian David Healy's extensively researched and well argued book, The Antidepressant Era. The book explores psychiatry's shift from psychoanalysis to biology -- and with it, its conceptualization and treatment of what the profession has defined as its professional turf -- in all of its murky detail. On one hand, as in many stories of science, this involves a narrative of discovery and implementation. Healy thus examines the discovery and development of pharmaceutical treatments of depression, from imipramine and chlorpromazine in the 1950s, to Prozac and the SSRIs of the current day. This part of the story is in many ways one of progress. In the space between these two medications and time periods, and in much of the first five chapters of The Antidepressant Era, medication treatments for depression and anxiety become increasingly safer and often more clinically effective. The telling of this component of the narrative is one Healy handles with an expert's eye for detail. The book, for example, is filled with enough side effect profiles, chemical structures, and clinical descriptions that a novice reader might well be able to differentiate a tricyclic from a MAO Inhibitor upon its completion.
But there is, as always, an underside to progress. As Healy compellingly points out in different ways throughout the book, "we ought not to be surprised but the story is, in many respects, far more complicated than one of simple independent discovery" (59).
And in this sense, the discovery tales of antidepressant medications become metonyms for a series of much larger wholes. The forces that complicate the story of antidepressants are many. These range, in successive chapters, from the pointed political struggles within the psychiatric establishment concerning the discovery of antidepressants, to the concomitant discourse over the validity of claims of efficacy, to the questions raised by pharmaceutical industry involvement in the pathologizing of what is defined as "disease." In so doing, Healy provides insight not only into how antidepressant medications rose from clinical outsiders to become the treatments-of-choice for depression in contemporary medicine, but also into the often conflicting politics involved in this ascent.
It is in this latter narrative that Healy excels. Indeed, The Antidepressant Era is at its strongest when it is at its most skeptical. In the book's final two chapters, for example, Healy raises interesting evidence that the success of psychotropic medications has as much to do with cultural factors as it does with clinical indication. Healy, moreover, is able to well merge the two. In the case of Panic Disorder, for example, Healy is effectively able to find a position concomitantly appreciative of the advances in pharmacology, and wary of the forces that have emerged as a result: "... the fact remains that panic has come from being virtually unrecognized in 1980 to being commonly diagnosed ... In this manner companies make their markets. It may often be far more effective to sell the indication than to focus on selling the treatment" (197-198).
The Antidepressant Era at times seems to get mired in the minutia of its subject. The book often wanders into long tangents on the history of medicine, which seem to have little to do with its central thesis. ("Paracelsus was born in Switzerland in 1493. He qualified as a physician in 1515. In 1526 he was appointed professor of medicine ..."(14)). These only detract from the book's purpose of analyzing psychiatry in the last half of the twentieth century. But Healy is just as frequently able to use these seemingly small details in the service of insightful connections between past and present. (Healy, for example, effectively connects the recent popularity of the SSRI antidepressants with the clinical tradition of Nathan Kline, inventor of the MAOI inhibitors 25 years earlier. The Prozac phenomenon, far from being remarkable, is in many respects directly within the Klinean tradition, both in mass use of the drug and also in the portrayal of Prozac as something of a psychic energizer rather than a thymoleptic. (70)). The result, then, is largely a work that both tells a narrative, and resists a narrative; and within this divergence, explains part of the reason why antidepressant medications have enjoyed clinical and economic success in the United States.
The book, however, ultimately suffers, not from excessive detail, but from several glaring acts of omission. Healy's sources, and the subjects they represent, come almost entirely from a mixture of biologically scientific articles, interviews with pioneers of psychopharmacology (Ayd, Berger), economic reports, and works of medical history (Grob, Shorter). A dependence on these sources seem to leave seemingly vital components of the antidepressant era unexamined. Psychoanalysis, for example, is given only the most superficial role in the narrative. This is not to say that psychoanalysis is not represented. It is (at six different points in the book, actually). But the demise of psychoanalysis, a central component in Healy's explanation of why medication and other brief therapies achieved such popular and prescriptive success, is explained solely in economic and political terms. "The 1960's and 1970's had seen the emergence of briefer and more focused cognitive and behavioral therapies. These clearly fitted the economic climate better than psychoanalysis" (237). While this may have been true, such an approach leaves major issued unaddressed. Psychoanalysis had been received as the miracle cure -- thirty years earlier -- in much the same way as medications. Presumably, there were many analysts practicing during the antidepressant era. How, then, did the analytic community try to adapt to their markedly shifting prestige? Did they reject medications? Did they try to incorporate medications into their treatments? Healy, in short, leaves out both the analytic community's reactions to the era, and the lessons that might be learned as a result. The effect is a rather one-sided description of psychiatry's apparent paradigm shift.
Women, more importantly, are hardly mentioned at all. This seems inexcusable in a narrative about psychotropic medication in the United States. The book begins and ends with the description of a young housewife, but its text is almost entirely dominated by the agency of the men of (an ill-defined) modern medicine (9). The book gives passing lip-service to "a particular concern about the greater use of tranquilizers among women" (226) -- a point which it neither pursues nor examines. Worse, it gives no basis for understanding these concerns. Were tranquilizers -- and later benzodiazepines and SSRIs -- disproportionately prescribed to women? (A very different issue than if they were over-prescribed in general). If so, why was this the case? If not, what was the source of this concern? Such information -- seemingly vital to the story -- would hardly be found in such referenced works as Ayd's Discoveries in Biological Psychiatry.
Such omissions can lead readers of The Antidepressant Era to a very different skepticism than the one Healy describes in his introduction (3). We can on one hand admire the detailed, thought-provoking work of an author who knows his subject matter well; and at the same time thank the good Lord for the existence of cultural studies, feminist theory, and contemporary psychoanalysis -- where we might find the other, unspoken parts of this story.